KC TRAINS

SPEAKERS B

Speaker’s Bureau

Kansas City Metropolitan

Library & Information Network

15624 E. US Highway 24

Independence, MO  64050

Phone:  (816) 521-7257

Fax:  (816) 461-0966

sburton@kcmlin.org

Application

You may photocopy this form as needed, then fax or mail one copy to the KC Trains Speaker’s Bureau Coordinator at the address below.  Please fill out all portions of this form.

Speaker: _____________________________________________________________________

Program: ____________________________________________________________________

Request the following Day, Date and Time for Program (please select two)

    First Choice _______________________________________________________________

    Second Choice _____________________________________________________________

Purpose of Program:  ____Staff Day  _____Dept. Meeting _____ Keynote _____ Staff Training

Program Location and Address: __________________________________________________

Sponsoring Organization: _______________________________________________________

Address: _____________________________________________________________________

City, State, Zip: _______________________________________________________________

Program Coordinator: __________________________________________________________

E-Mail: _____________________________________________________________________

Work Phone: _______________  Cell Phone: ______________ Home Phone: _____________

We will contact you on the availability of this speaker and costs for the presentation.

Estimated Attendance: _________________________________________________________